"Health Care For All" in lights on a bridge

A Healthy Blog

Massachusetts health care – wonky with a dose of reality

June 29, 2005

Congress isn’t the only battleground in the fight to preserve Medicaid. Several states are considering deep cuts in their Medicaid programs. The most critical is Tennessee, where Gov. Phil Bredesen has proposed the largest cutback of state public health programs in the nation's history. Gov. Bredesen would strip 323,000 Tennesseans of their health coverage, including 97,000 with chronic conditions and high health care costs. His plan would saddle 396,000 enrollees, no matter how sick, with arbitrary limits on their care. It is likely many beneficiaries will become sicker, and some will die, as a result of losing coverage.

Bredesen makes no secret of his desire to export his vision to destroy Medicaid to the nation. FamiliesUSA has set up an online petition urging Gov. Bredesen to renounce his plan to strip 323,000 Tennesseans of their health coverage. Please sign the petition by clicking here -- only takes a few seconds.

Bredeson's vision of national Medicaid reform would impose onerous cost-sharing requirements and arbitrary limits on services for beneficiaries. Because of Gov. Bredesen’s increasingly visible national profile, his actions could have negative national repercussions for Medicaid. There is a clear danger for national Medicaid reform—as Tennessee goes, so might go the nation.

June 28, 2005

Meanwhile, the ever-excellent Mass. Medicaid Policy Institute has just released a new report: Ten Facts the Employer Community Should know about the Massachusetts Medicaid Program, a new report that provides perspectives about the importance of MassHealth for the state's business community. In particular, the report explains how a strong MassHealth program benefits employers.

"Although many associate MassHealth with poverty and unemployment, it is a major source of health insurance for low-wage workers, covering more than 400,000 employed persons and their families. MassHealth is a major reason why Massachusetts has a relatively low percentage of people withour insurance, and program expansions have helped reduce the cost of uncompensated care, financed in part by business."

Congrats to Nancy Turnbull and Bob Seifert for another outstanding piece of work.

June 27, 2005

This is from the letters page of yesterday's Boston Globe.

Why I don't have healthcare

June 26, 2005

REGARDING ''Romney eyes penalties for those lacking insurance," (Page A1, June 22): I am a 45-year-old single mother with two teenaged children, one full-time job, and one part- time job. I own a home and pay nearly $4,000 annually in taxes to the Commonwealth. However, my full-time job as a secretary in a small office does not provide me with health insurance, and I earn too much to qualify for MassHealth. My children, fortunately, are covered by their father's insurance policy.

Most of us who ''choose" not to have health insurance are forced into that choice by finances. My expenses exceed my income by approximately $100 a week. I resent the implication in the article that my intention is to defraud the healthcare industry by seeking out medical care and then refusing to pay.

I welcome any suggestions Governor Romney might have as to how I might enroll in a plan, avoid foreclosure on my home, continue to keep my children fed, clothed, and warm, and pay my already substantial taxes. In his proposed run for the presidency, it might better serve him to find a way to make health insurance affordable for everyone rather than penalize those of us who are unable to afford it.


June 26, 2005

The nation's governors are on the warpath about Medicaid, looking for ways to cut and trim, and complaining that Medicaid consumes on average 22% of state budgets on average. The Congressional Research Service has just released a report that provides a more honest way of understanding the impact of Medicaid on state budgets. Because more than half of Medicaid is financed with federal dollars, the real state tax hit from Medicaid is far less than that amount -- about 12.7% in FY2004. Also of interest is how Massachusetts stacks up among states with the highest Medicaid hit on state tax dollars. Here's the list:
Ohio -- 25.2%
Tennessee -- 20.4%
Connecticut -- 19.8%
Pennsylvania -- 19.2%
New Hampshire -- 18.9%
Illinois -- 17.8%
Missouri -- 17.1%
Rhode Island -- 15.1%
New York -- 14.4%
Vermont -- 13.9%
Texas -- 13.8%
Florida -- 13.0%
New Jersey -- 12.9%
Michigan -- 12.9%
Maine -- 12.5%
Colorado -- 12.5%
Nevada -- 12.5%
Minnesota -- 12.4%
Massachusetts -- 12.2%
National Average -- 12.7%

Yahoo, we're #19! OK, let's put this in some context. Other states are so low because they spend so little on much of anything -- hello Texas! But that's not the whole story. Truth is: we're not way out there in Massachusetts on Medicaid spending as a portion of how state tax dollars are used. Not by a mile.

June 25, 2005

Here's a contribution from a visitor to HCFA's website:

Just paid our 1123 premium for the month. This is for a family of 3. That is co-pays on visits, drugs, hosp visits. And of course no dental. How many people do you know that could afford this premium? If the govt (all parties) wanted us to ALL have med coverage then they should do this:

1. allow us the self insured / self employed to fully deduct all insurance premiums off taxes. That includes federal and state taxes.

2. allow us to get the same reduced price for premiums that municipal workers pay for it.

3. allow us to purchase ins without paying into "a group" which is a couple of hundred dollars per year. That is another expense.

Small businesses are an American idea. What is happening is the small business person cannot afford med insurance. We will all see our property taxes increase in the next few years when municipal workers take early retirements and we are forced to pay their medical costs till they get to 65. Those fixed costs are never challenged and cuts occur with schools, police, and fire depts which affect all of us.

Lastly I would like to see all elected officials lose their health coverage. Let them deal with the above expenses. Things would have a better chance of getting fixed a whole lot sooner. I would love to sign a ballot petition and vote for that! I am starting to lean Libertarian where one has less taxes and takes care of themselves as the current system seems to be eliminating the middle class.


June 24, 2005

Give Gov. Romney credit -- he's put a big idea in play with the Safety Net Care Plan he outlined this past week. A sitting Governor proposing a mandate on all individuals to purchase health insurance is a big idea. Others, such as former LA Senator John Breaux, talked about it. Romney's putting it into play for real. And it deserves attention. So let's give it some -- after several days reflection and discussion, in no particular order.

First, if the Administration wants the public and the policy community to take this seriously, they must be transparent in their thought process. This Administration thrives on giving us op-ed columns and powerpoint outlines, and nothing else. That doesn't cut it. Look at the Blue Cross Roadmap to Coverage report -- that's the kind of detail a serious gubernatorial initiative has a responsibility to provide -- back up for numbers, assumptions, detail. Otherwise, we have to consider the possibility they're just making up numbers to look good on the screen.

Second, connected to the first. Remember in April, Romney released the first part of his health plan -- Commonwealth Care, the low cost insurance plan for higher income uninsured (over 300% federal poverty line -- $58K for a family of 4). All these plans would be out there with a price point of $200 per month for an individual policy. Again, details provided to the public going no deeper than a powerpoint and a bill that says far less than it discloses. The health plans, being nice to the Governor, say: "Oh yeah, we can do that." Two and a half months later, do we have even one insurer who has come forward and said -- we can do this, and here's exactly what such a plan will look like"? Nope. And Romney acts like he's put it all out there on Commonwealth Care. Not even close, not by a country mile.

Third, there's a troubling tone to the Governor's comments on the individual mandate. On Wednesday, in talking with reporters, he likens it to "workfare" -- the requirement for folks on welfare to work. He suggests poor people are getting free care and getting away with murder. His chief policy aide, Tim Murphy, says to the Globe in May that hospitals are being too lenient in not collecting unpaid bills. And. outrageously, Romney suggests that the state set itself up as the collection agency for health care providers -- garnishing the wages of folks who can't pay off their hospital debts. Maybe it's just posturing or pandering to his conservative base, yet there's an edge here that's disturbing.

Why? First, about 80% of the uninsured are workers, who go to their jobs every day, pay taxes, I just wish, just once, Romney could show a scintilla of awareness of how difficult life is for folks in the bottom half of the income spectrum. Maybe we could lock him in a room and not let him out until he's read David Shipler's incredible book -- The Working Poor: Invisible in America. People getting subsidized health coverage don't get a single dime in their pocket -- they get medically necessary services approved by a licensed provider. The Governor's rhetoric makes it harder for folks to take his intentions seriously.

Fourth, the silence from the Legislature in response to Romney's announcement is absolutely deafening. A handful of legislators were in the audience -- Sen. Dick Moore, Rep. Jim Marzilli, Rep. Harriet Stanley, among others. Will this be greeted as a serious contribution or a passing fancy/campaign stunt from a guy heading for the door? Really hard to tell.

Fifth, Romney keeps saying that we must do this or we face the loss of big federal dollars beginning on July 1, 2006 in connection with the renewal of the state's Medicaid waiver. Knowledgable sources -- not me -- question this assertion and make reference to the actual waiver renewal document between the feds and the state. No doubt, the state has some financial rearranging to do in terms of money sources and uses -- yet I confess, I can't find anything in the document that requires us to come up with an entirely new structure for the health care safety net.

Sixth, back to the individual mandate. Here's the question -- Romney clearly has no trouble mandating all kinds of things on individuals -- as consumers, as patients, as taxpayers -- and throwing lots of penalties their way if they don't do the right thing. Why let employers off the hook? Why? Last February, the State documented that hundreds of large employers cost the state more than $50 million per year when their workers go to MassHealth or the Free Care Pool because employer benefits weren't adequate. Walmart is one of the most profitable companies on the planet -- why let them off the hook? Is it good policy or politics?

June 23, 2005

From HCFA Policy Director Brian Rosman: The conference report budget for FY 2006 was filed with the clerks at 3:00 am this morning. The House will vote on the budget at 1:00 pm this afternoon. It's an up or down vote - no amendments are allowed. The Senate vote will come after. The budget includes a number of wins on most of our key priorities:

  • restoration of MassHealth dental coverage for pregnant women and mothers of children under 3;
  • restoration of an affordable premium schedule for the Childrens Medical Security Plan;
  • a requirement that MassHealth hold a public hearing before restricting eligibility or benefits;
  • a requirement that the enrollment outreach grants must include funding the Covering Kids and Families program and the Western Mass Health Access Network;
  • an open enrollment period for Prescription Advantage and a requirement that the program cover costs not covered by Medicare. The budget does not include the $5 million appropriated by the Senate to subsidize copayments in the program, but does use the Senate budget figure for the overall program which was about $2 million higher than the House number.

The budget also includes two priorities that were in both the House and Senate bills: coverage for elder and disabled legal immigrants, and permitting dentists to limit MassHealth caseloads.

The budget include one major disappointment. The MassHealth Essential program is funded at the current capped caseload level. Unless additional funds are appropriated in a later supplemental budget, eligible applicants will continue to be placed on the waiting list. This is particularly disappointing as the Governor signaled in the past few days that the administration would support re-opening the Essential program if funding were provided.

The budget also did not include our outside section to repeal authorization for caps in the HIV and CommonHealth programs. The budget did include $18 million to restore MassHealth coverage for hospital stays beyond 20 days.

June 22, 2005

We don't talk much about medical malpractice in this space. But every issue gets its turn sooner or later. Yesterday's Wall Street Journal had an keeper article about malpractice: "Once Seen As Risky, One Group of Doctors Changes Its Ways: Anesthesiologists Now Offer Model of How to Improve Safety, Lower Premiums." Here's a brief excerpt:

"The rising cost of medical-malpractice insurance has hit many doctors, especially surgeons and obstetricians. But one specialty has largely shielded itself: Anesthesiologists pay less for malpractice insurance today, in constant dollars, than they did 20 years ago. That's mainly because some anesthesiologists chose a path many doctors in other specialties did not. Rather than pushing for laws that would protect them against patient lawsuits, these anesthesiologists focused on improving patient safety. Their theory: Less harm to patients would mean fewer lawsuits.

"Over the past two decades, anesthesiologists have advocated the use of devices that alert doctors to potentially fatal problems in the operating room. They have helped develop computerized mannequins that simulate real-life surgical crises. And they have pressed for procedures that protect unconscious patients from potential carbon-monoxide poisoning.

"All this has helped save lives. Over the past two decades, patient deaths due to anesthesia have declined to one death per 200,000 to 300,000 cases from one for every 5,000 cases, according to studies compiled by the Institute of Medicine, an arm of the National Academies, a leading scientific advisory body.

"Malpractice payments involving the nation's 30,000 anesthesiologists are down, too, and anesthesiologists typically pay some of the smallest malpractice premiums around. That's a huge change from when they were considered among the riskiest doctors to insure. Nationwide, the average annual premium for anesthesiologists is less than $21,000, according to a survey by the American Society of Anesthesiologists. An obstetrician might pay 10 times that amount, Medical Liability Monitor, an industry newsletter, reports."

I learned about the transformation in anesthesiology years ago at Brandeis. It's great to see this important story documented. The message is clear -- the liability crisis solution has to be about more than just capping awards to injured patients.

June 21, 2005

Today, Gov. Romney spoke at the Blue Cross Foundation's Summit at the JFK Library and revealed more details of his health reform plan. Before today's event, the Governor revealed his plans in a Boston Herald op-ed column. This is the second time (last November was the first) that the Gov. has revealed a policy initiative with an op-ed column accompanied by a powerpoint slide show.

Revealing is what's missing -- namely, anything else. I'm old fashioned -- and I long for the days when gubernatorial initiatives were accompanied by legislation and detailed policy briefs that spelled out assumptions, numbers, and details. This governor accompanies his pronouncements with zero details, making it impossible to evaluate. So the Gov. says we're spending about $947 million now for care for the uninsured, and his plan will spend -- voila -- $947 million. Believable? Who knows because the Administration keeps its numbers to itself. The Gov. embraces the fashionable notion of "transparency" in health care. A little "policy transparency" would set a good example.

Beyond this, what's new? The Gov. talks about "personal responsibility," coming close to embracing an "individual mandate" to require individuals to purchase insurance. Scofflaws would face the loss of their personal tax exemption, and the Gov. would have the state garnish the wages of uninsured folks with unpaid medical bills. No tough talk, though, for employers who don't cover their workers. They're off the hook. Our sense is that the Romney plan provides a huge incentive for many employers to stop offering coverage.

Where's this stuff come from? The Gov. (and his staff) say they've been talking with the Heritage Foundation, the right wing Washington DC think tank that wants to replace employer sponsored health insurance with individual insurance, and that champions Health Savings Accounts that stick consumers with high deductibles. Governor Romney admits to holding conference calls with Americans for Tax Reform's Grover Norquist -- America's leading right wing demagogue -- to consult on tax policy. Now he's turning his health policy development over to the Heritage Foundation.

June 20, 2005

Informed sources tell us that at tomorrow morning's Blue Cross Blue Shield Access Summit, Governor Romney will publicly embrace a mandate for all individuals in Massachusetts to buy health insurance. He will also call for major reform elements promoted by other plans (Affordable Care Today Coalition, Sen. Pres. Travaglini) such as reinsurance, provider rate reform, a free rider surcharge, new public spending, and more.

The Summit takes place at the JFK Library between 8:30am and 12:30pm and Gov. Romney is the keynote speaker at 8:30. The Foundation will release the next version of its "Roadmap to Coverage" report, including important details on the ways to finance a major coverage expansion for the uninsured. No leaks on that!

If Gov. Romney embraces an individual mandate and new health spending, he will be moving significantly forward in his thinking, and we welcome this significant new development. There are reasons to be cautious, ie:

If the plan does not contain significant subsidies for low and moderate income persons, the individual mandate will be completely unworkable;

If the plan contains unaffordable cost sharing -- copays, deductibles, premiums -- it will also be unworkable;

An individual mandate could become a major incentive for employers now providing coverage to workers to stop doing so -- a huge cost shift from businesses to individuals and to taxpayers.

That being said, we're delighted to see Governor Romney embrace new spending and mandates. What's coming next?